CG-SURG-51 Outpatient Cystourethroscopy

This policy addresses outpatient cystourethroscopy (combined cystoscopy and urethroscopy). It is medically necessary for: gross hematuria without evidence of glomerular disease or infection; gross hematuria with blood clots; microscopic hematuria without evidence of glomerular disease, infection, or known cause when there is increased risk for malignancy; or management of kidney stones unlikely to pass spontaneously. It is considered not medically necessary for any other indications.

"Outpatient cystourethroscopy is consideredmedically necessaryforanyof the following indications:"

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